GeBBS Healthcare Blog

CMS Will Only Adjust Medicaid Rules – Not Drastically Change Them

Posted on Tue, Nov 20, 2018 @ 05:00 AM

After much ballyhoo and for years of promising a major overhaul to the cost-prohibitive Obama-era managed care rules, the CMS has issued a proposed regulation that makes smaller changes – not the drastic “gutting” that had been promised -- to the standards states meet when running their Medicaid plans.

The proposed rule issued Thursday would give states some new flexibility in setting rates for their managed care plans and ensuring insurance companies have adequate provider networks. There still no oversight on how private insurance companies managing these state plans use the money for patient care and the profits they can reap.

The agency estimates that the changes it's proposing would cut states' administrative costs by $27 million, or 120,000 hours less in clerical tasks.

The new proposed rule doesn't affect the key linchpin of the Obama-era rulemaking, which set a federal medical-loss ratio (MLR) of 85%. That means all insurers must spend at least 85% of their Medicaid revenue on medical care and other activities that improve quality.

The Trump-era CMS has said it supports the 85% MLR provision because it believes it will help control spending in the program.

The new rule focuses on states' secondary concerns. For instance, the Obama rulemaking required states to develop and enforce minimum travel time and distance standards for providers. Medicaid directors have complained this policy wouldn't improve network adequacy, noting that there's no guarantee a provider or specialist practices within certain distance of a patient.

The proposed rule would allow states to use quantitative standards to judge plans' networks. That could include data such as how long it takes for a patient to get an appointment or provider-to-patient ratios.

CMS has said they believe that this change would enable states to choose from a variety of quantitative network adequacy standards that meet the needs of their respective Medicaid programs in more meaningful and effective ways.

It seems to me the more things change the more they stay the same.

GeBBS Healthcare Solutions is a leading technology-enabled provider of revenue cycle management (RCM) and Government Payer solutions. GeBBS’ innovative technology, combined with its over 6,000-strong global workforce, helps clients improve financial performance, compliance, and patient satisfaction. Visit our website to see how our services can work for you.


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Tags: RCM Solutions, Revenue Cycle Solutions

Billions of Dollars Flow into Private Medicaid Plans with NO Cost Oversight or Efficacy of Treatment Determined

Posted on Wed, Nov 07, 2018 @ 10:52 AM

Cost containment has become a leading factor in the delivery of healthcare. What are some of the issues that are contributing to these burgeoning costs? One of them is Medicaid. We spent over $576 billion on Medicaid programs in 2017, as reported by the Kaiser Family Foundation.

A recent article in Kaiser Health News noted that 75 million low-income Americans rely on private Medicaid managed care programs. These programs have grown rapidly since 2014, boosted by the influx of new beneficiaries under the Affordable Care Act (ACA). Many states eagerly tapped into the services of private insurers as one way to cope with the expansion of Medicaid costs under the ACA, which has added 12 million people to the rolls. Outsourcing these government-payer programs to private insurers has become the preferred method for handling Medicaid in 38 states.

In return for their fixed fees, these private insurers provide treatment within a limited network -- in theory -- allowing for more judicious, less expensive care. States contract with health plans as a way to lock in some predictability in their annual budgets. Participating states in these private programs are funneling nearly $300 billion annually into private Medicaid insurers.

Are these private Medicaid insurance companies -- who are now receiving hundreds of billions in public money — earning their fees?

Hard evidence is lacking that these private contractors improve patient care or save government money. When auditors, lawmakers and regulators examine the records, many conclude that private Medicaid insurers fail to account for the dollars spent, document the care delivered, or provide access to a sufficient number of doctors. Oversight is sorely lacking and lawmakers in a number of states have raised alarms even as they continue to pay billions. Another “fly in the ointment” is that these private plans get to keep what they don’t spend. That means profits can flow from greater efficiency -- or from skimping on care and taking in excess government payments.

What is the solution to cost containment on these government-funded private payer programs?

Independent outsourced auditors who have deep experience in auditing insurance claims and determining the efficacy and quality of medical treatments can be utilized to monitor these privately managed care plans.

These independent outsourced auditors will have the information technology solutions to deliver highly skilled professionals, robust audit processes, proprietary workflow engines, and world-class IT infrastructures.

They can deliver immediately audit workflow and operations management to ensure consistency throughout the managed care plan audit process that will monitor and report the true cost of medical treatments and the quality of care being provided to patients.

Let’s get the “fox out of the henhouse” and move toward a system that will contain costs, and more importantly, improve the patient care being delivered.

GeBBS Healthcare Solutions is a leading technology-enabled provider of revenue cycle management (RCM) and Government Payer solutions. GeBBS’ innovative technology, combined with its over 6,000-strong global workforce, helps clients improve financial performance, compliance, and patient satisfaction. Visit our website to see how our services can work for you.


If you liked our blog please like, share, and comment!


Tags: RCM Solutions, Revenue Cycle Solutions

Outsourcing as a Solution for Revenue Cycle Management (RCM) Continues to Grow at a Rapid Pace

Posted on Wed, Feb 22, 2017 @ 06:00 AM

Facing lower reimbursements and shrinking margins, hospitals are exploring ways to capture more revenue. This has led an increasing number of hospitals across the nation to outsource their revenue cycle management to professional outsourcing companies. This trend was identified in a recent Black Book™ survey, which included responses from 1,309 hospital CFOs and business office leaders. The surveyed revealed that 39.8 percent of U.S. hospitals outsourced their complex claims and revenue cycle management to specialized vendors. That is up from 20.4 percent of hospitals in 2013.


Hospital billing and collections staffs typically do not have the experience in handling complex revenue cycle management challenges, causing a significant number of claims to be written-off.

Many hospitals are turning to outsourcing to reduce those write-offs and give their organizations a financial boost. According to the Black Book survey, 49 percent of hospital CFOs said outsourcing, including offshoring, is becoming an extremely viable option in 2017 for their organization’s revenue cycle management. Black Book projects the market for outsourced revenue cycle management will grow at a compound annual growth rate of 26.5 percent over the next two years, with the market reaching a value of $9.7 billion by 2018.

The next challenge for hospital financial managers is to choose the right outsourcing partner. CFOs should select an outsourcing partner that has a national recognition as a provider of RCM and HIM solutions. They should choose a company that has an in-depth healthcare industry knowledge and has the expertise to provide innovative, end-to-end solutions that will successfully resolve their complex RCM challenges, while enhancing their overall business operations.

This kind of outsourcing partner can leverage deep industry knowledge and expertise, and provide a partnership approach with comprehensive service offerings. They will deliver highly skilled professionals, robust processes, proprietary workflow engines, and world-class infrastructure to reduce operating and capital costs, recover revenue, improve patient satisfaction, and increase productivity.

This week, the IAOP® has named GeBBS Healthcare Solutions to its 2017 Global 100 Outsourcing List, an annual listing of the world’s best outsourcing service providers. We were recognized as an industry leader in healthcare revenue cycle optimization outsourcing solutions for the second year in a row that was judged in five main categories: size and growth, customer references, awards and certifications, programs for innovation, and corporate social responsibility.

It extends GeBBS’ long history of awards.  Modern Healthcare has listed us as one of the nation’s top 15 largest revenue-cycle management companies for 2016 and we’ve been recognized as one of the top 20 outsourcing providers for revenue cycle management for hospitals 100 beds and up, according to Black Book Market Research.

As hospitals are forced to do more with less, outsourcing provides the scale necessary to optimize revenue from complex claims collections to end-to-end revenue cycle management. Be sure to select an outsourcing partner that fully understands your healthcare RCM needs.

Tags: Business Process Outsourcing (BPO), Revenue Cycle Management (RCM), Offshore Medical Billing, Offshore Medical Coding, Outsource Coding, outsourced coding, outsourced medical billing, Offshore Revenue Cycle Management, coding outsourcing, RCM Solutions

Two Couples Break-Up on Valentine’s Day

Posted on Wed, Feb 15, 2017 @ 02:50 PM

By Nitin Thakor, GeBBS President & CEO

Cigna ended its merger agreement with Anthem on Valentine’s Day and said it will seek $13 billion in damages from Anthem on top of the $1.85 billion break-up fee outlined in the deal. The planned $54 billion merger was blocked by a federal district court last week on anti-competitive grounds. Cigna said the reason for the break-up was that the potential alliance cannot and will not achieve regulatory approval and was calling off the deal in the best interest of its shareholders. Industry analysts are projecting that Anthem will not pay the break-up fee without a fight.


Also ironically on Valentine’s Day, another merger went sour. Aetna and Humana announced they had terminated their $37 billion merger following a U.S. district court judge's ruling against the deal.

In this case, Aetna will not seek an appeal and instead will pay Humana $1 billion to terminate the agreement. Aetna will also pay Molina Healthcare a break-up fee to end their agreement. Aetna had agreed to sell Molina some of its Medicare Advantage plans to win court approval for the Humana deal.

What does all of this mean?

While both mergers were blocked for different reasons, there is at least one conclusion that can be drawn from both. Industry analysts are saying that the courts have been quick to embrace the flexibility and creativity of the Obama administration’s antitrust enforcers in terms of defining product markets.

With a new administration in power, all of that could change. It’s anyone’s guess which way it will go. President Trump’s actions have not matched any previous administrations. He’s been very surprising in many different ways.

My guess is that the fast pace of enforcement we saw under the Obama administration appointees will slow, but I don’t think it will disappear. Consolidation in the insurance industry isn’t going away. It’s very likely that the mega-mergers will slow down, but larger companies may decide to pick off smaller competitors farther down the chain. More importantly, in my opinion, this will be the impact of the planned repeal of ACA. Let’s wait and see what Congress and the President are able to accomplish with this and how they plan to reconfigure the provision of health insurance and healthcare services.

Tags: Best Practices, RCM Solutions, Revenue Cycle Solutions

Be Prepared for "Surprise" Medical Billing

Posted on Wed, Feb 08, 2017 @ 12:45 PM

A recent article on the Radiology Business Management Association (RBMA) web site discussed consumer’s frustration with the cost of medical care as being at an all-time high as many purchasers of narrow-network, high-deductible and high-co-pay health plans are finding out that the benefits they get from their monthly insurance premiums are much more limited than they thought. One target of their frustration is “surprise” medical bills for services such as radiology, as well as other medical specialty services that a patient may receive from an out-of-network (OON) physician, while either receiving emergency care or a planned treatment at an in-network facility. It is an issue that has been covered by the likes of Consumer Reports and numerous other publications in recent years.  In response, state legislators in nearly two dozen states are either considering or have already passed laws to protect patients from such unexpected/surprise bills.


Both California and New York have passed “Surprise” Medical Billing laws. The California Law applies to plans and insurance policies issued in California, amended, or renewed after July 1, 2017.

It is important for providers, health plans, and insurers in California to quickly create a plan to successfully navigate this new law. It is also important to note that these new California and New York regulations may be harbingers of laws elsewhere as it represents the next step in the evolution of state legislative efforts to address the tricky issues that arise when beneficiaries receiving OON services without a reasonable opportunity to consent to them.

This is precisely the time to engage with a partner who brings a deep understanding of the revenue cycle and provides tailored insurance billing solutions that cut through the complexity with expertise, operational excellence, and a sophisticated approach. An expert outsourced billing partner can deliver solutions specific to each client’s need, while working with a client’s host system and using its tools to build efficient workflow processes with higher output through the use of a hybrid of automated and manual solutions.

The healthcare environment is changing with these new “surprise” medical billing laws, The Affordable Care Act and whatever evolution may follow, and the transition to ICD-10 all put added layers of expense and complexity on our already burdened billing systems.  Patient volumes are on the rise with the newly-insured population, and high-deductible plans putting added pressures on revenue cycle operations and the drive to collect payments. 

The key to success is access to a large pool of outsourced, qualified denial management experts who can work in any healthcare environment and that understand the new compliance laws, such as “surprise billing,” and how to quickly and correctly analyze account history, appeal denied claims, and get timely turnaround to recover on and close out A/R.  Outsourced RCM analysts adept at trending denials and looking for patterns of deficiency will increase cash flow and reduce aging A/R.

Tags: Revenue Cycle Management (RCM), Patient Access Management, Offshore Medical Billing, Medical Billing BPO, outsourced medical billing, RCM Solutions

High Deductible Self-Pay Accounts Can Be a Major Threat to Revenue Cycle Management

Posted on Thu, Jan 26, 2017 @ 05:00 AM

According to data from the latest quarterly Crowe RCA Benchmarking Analysis: "Patient Financial Responsibility on the Rise,” healthcare providers could be facing a major threat to their revenue cycles. The analysis found that in the past year, insured patient financial responsibility has grown from 23.3 percent to 26.9 percent for outpatients and 10.2 percent to 12.1 percent for inpatients.


This new revenue cycle threat comes from the fact that patients continue to take on more financial responsibility for their care due to participating in high-deductible health plans, especially those of the Affordable Care Act, (ACA). In 2017, the out-of-pocket maximum for ACA can range from $7,150 for an individual plan to $14,300 for a family plan before marketplace subsidies kick in. Healthcare providers are struggling with collection rates as they try to adapt to increasing patient responsibility amounts for insured self-pay co-pays and deductibles, according to the Crowe benchmarking data.

This trend is expected to grow over the next few years. As a result, both patient liability and bad debt are on the rise and healthcare providers are experiencing unprecedented revenue and margin pressure. Hospitals and clinics have become like retail organizations, which need to provide their consumers with access to payment capabilities at point of service, via the web, through payment plans, and more. The answer for healthcare providers is to take advantage of professional outsourcing companies who have expertise in patient access management solutions that can improve patient satisfaction, while lowering your collection costs and increasing revenue.  These necessary outsourcing services include:

- Scheduling, Eligibility Verification, and Pre-Authorization
- Patient Call Center
- Self-Pay Collections

Self-pay collection is the most critical of these services. A recent McKinsey study found that 74 percent of insured consumers indicated that they are both able and willing to pay their out-of-pocket medical expenses up to $1,000 per year and 90 percent would pay for medical expenses up to $500 per year.

Reasons for a rise in self-pay bad debts are due in part to inefficient and ineffective collection practices followed by most billing companies and physician practices. An expert self-pay collections team uses technology-enabled practices to maximize patient contact with:

  • - Easy to understand patient statements
  • - Automated dialers
  • - Digital messaging campaigns
  • - Mobile technology to drive text messaging campaigns

The outsourced self-pay collections team leverages analytics to arrive at the best time to contact patients and their propensity to pay scores to create outbound campaigns that are patient experience-oriented, non-obtrusive, and drive higher patient connect ratios.

Don’t let high-deductible, self-pay insurance amounts wreck your revenue cycle. Work with an experienced outsourcing team that will provide your patients with flexible payment options and easy access to payment capabilities for web, phone, credit card, and e-check payments.

Tags: Revenue Cycle Management (RCM), Patient Access Management, RCM Solutions

What Will Be the Effects of Merger Mania on the Delivery of Healthcare?

Posted on Fri, Jan 20, 2017 @ 05:00 AM

By Nitin Thakor, GeBBS President & CEO

A Healthcare Finance News article last year quoted a New Jersey hospital executive as saying: “Big is going to be better; small is not going to survive.” Time will tell if he is right, but most industry analysts agree that the coming year will be full of acquisitions and mergers as hospitals, health systems, information technology companies, software firms, medical practices and other healthcare service providers seek to discover whether or not bigger is indeed better in the new world of the Affordable Care Act (ACA) -- and whatever evolves from its planned repeal and replacement.


A prime example is United Health’s recent announcement that their Optum unit would buy Surgical Care Affiliates for about $2.30 billion, creating a comprehensive ambulatory care services platform, including primary care, urgent care, and surgical care services. Surgical Care and its affiliates serve about one million patients per year in more than 30 states and operate 205 surgical facilities, including ambulatory surgery centers.
Not all provider realignments will be associated with mergers and acquisitions, some will come as partnerships to support better clinical integration and improved care delivery. The new CMS value-based payment reimbursement models create incentives to focus on prevention and the need for hospitals and healthcare systems to work together more efficiently.  Even if health reforms, such as the new Quality Payment Programs under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, weren’t enacted, pressures in the private marketplace would have driven healthcare providers in this direction.
There is no doubt that market forces, including the enactment of ACA and other reimbursement issues, began the mergers and acquisition movement and continue to drive its mania. Healthcare is moving from being hospital-centered to population-health centered. Managing this transition requires providers to operate multiple local delivery centers to hold down costs and provide healthcare at a local setting.
Mergers also offer the opportunity to produce a cost savings, both in back office functions -- such as purchasing, revenue cycle and IT -- and ultimately enhance healthcare delivery through improved, standardized clinical protocols.
Only time will tell whether or not bigger is indeed better in the new world of whatever evolves from the planned repeal and replacement of the Affordable Care Act.

Tags: Best Practices, RCM Solutions, Revenue Cycle Solutions

Specificity of ICD-10 Coding Can Improve Reimbursements for Vaccine Administration

Posted on Wed, Jan 11, 2017 @ 10:15 AM

Administration of vaccines is an important part of healthcare delivery, and a critical contribution to preventive public healthcare. However, risings costs are making it difficult to align vaccine administration expenses with revenues.

There may be some relief to these rising costs and it comes from something that was once seen as a burden for medical practices. That relief comes in the form of ICD-10 coding.


The transition to ICD-10 was seen as an administrative burden for many practices, but it does offer some relief in aligning vaccination reimbursement with actual costs. Compared to the previous coding system, ICD-10 recognizes the type of vaccine provided by the CPT or HCPCS code entered, negating the need for individual diagnosis codes.

The American Academy of Family Physicians (AAFP) offers specific coding guidance for practice billing patients covered by Medicare Part B and Medicare Part D. The Centers for Medicare & Medicaid Services (CMS) also offers guidance on choosing the right code for adult vaccinations, including the seasonal flu shot.

Correct coding is essential to receiving the proper reimbursements. A robust Health Information Management (HIM) coding program has never been more critical to the success of healthcare organizations than it is now. If your practice is not sure whether or not you have the expertise to code properly and receive the optimum reimbursements you deserve, it’s time to engage with a partner who brings a deep understanding of how proper coding affects the revenue cycle.

GeBBS Healthcare Solutions provides Health Information Management (HIM) solutions that cut through the complexity with expertise, operational excellence, and a sophisticated approach. We are a leading provider of outsourced medical coding and coding validation audits, and we have a unique insight into your challenges when it comes to data quality and coding accuracy, productivity, and reliability.

Let our team of expertly trained and qualified Health Information Management coders, who adhere to the best practices in the HIM coding field, make sure you receive the optimum reimbursements for your vaccine administrations.

Tags: ICD-10, Revenue Cycle Management (RCM), Medical Coding, outsourced medical coding, outsourced coding, coding outsourcing, Medical Coding BPO, RCM Solutions

AHA President and CEO Asks President-Elect Trump For "Steady as She Goes" Effort on Healthcare

Posted on Tue, Dec 20, 2016 @ 11:00 AM

By Nitin Thakor, GeBBS President & CEO

AHA President and CEO Rick Pollack recently sent a congratulatory letter to President-elect Donald Trump and asking him to go slowly on changes to our healthcare delivery system, particularly when it comes to the Affordable Care Act (ACA). This is good advice since healthcare represents a significant portion of the U.S. economy and essential public services. Pollack explained his case in terms that abrupt changes could lead to significant instability for patients, providers, insurers and others.


However, he was not so cautious when it came to Stage 3 Meaningful Use and M&A mergers. Pollack urged the President-elect to cancel Stage 3 of Meaningful Use, standardize the M&A merger review process, and reform the RAC program.

Pollack's letter highlighted five areas of concern for hospitals: reducing the regulatory burden; enhancing affordability and value; continuing to promote quality and patient safety; ensuring access to care and coverage; and continuing to advance healthcare system transformation and innovation.

In my opinion, much of what Mr. Pollack asked for makes perfect sense. It is my sincere hope that President-elect Trump will understand the consequences of abrupt changes to any financial system. He has already softened his stance on cancelling ACA on Day One of his administration. There are many things wrong with the ACA and reform is needed. I am hopeful that thoughtful men and women of goodwill will come up with a new plan that includes more participation of the private sector and the ability to sell health insurance across state lines.

This will provide a replacement plan that continues to provide a mechanism for individuals to obtain affordable insurance coverage, with realistic deductible amounts. Everyone who works in healthcare knows that the regulatory burdens faced by hospitals and physicians are substantial and unsustainable.

I remain hopeful that thoughtful reform can be accomplished, and we look forward to working within this new healthcare delivery system.

Tags: Revenue Cycle Management (RCM), Healthcare Revenue Billing, Best Practices, Insurance Billing Solutions, Medical Billing BPO, RCM Solutions, Revenue Cycle Solutions

Beware of Secondary Injury to Your Wallet after an ER Visit

Posted on Tue, Dec 13, 2016 @ 03:00 PM

A recent article in US News and World Reportexplained a little known fact of which most patients are completely unaware. A trip to the emergency room could cause a secondary injury to a patient’s wallet. Even if a patient goes to a hospital included in his or her health insurance network, if the emergency room physician who treats the patient is not part of the health insurance network, the patient will be responsible for a separate and unexpected bill.


Is this a big problem?

Research conducted by Yale University found that roughly 2 of 10 in-network visits involved a doctor not in the patient's insurance network. Going to an in-network hospital does not mean all your charges will be covered.

There is some slight hope in these situations. If you are attended by an out-of-network doctor, it doesn't necessarily mean financial calamity. That can depend, in part, on the patient's insurance coverage. And, some states like New York have laws that offer some protection against surprise bills, although the extent of that protection varies.

There are limited options to rectify the unexpected charges. Patients can ask that the claim be processed again as in-network care since the patient had no way of knowing the doctor was out of network or they can try to negotiate a lower bill.

In recent years, especially since the creation of the Affordable Care Act's public insurance exchanges, insurers have formed networks of doctors and hospitals, in part, to gain some leverage for negotiating reimbursements.

When the medical treatment is an emergency situation, you don’t always have time to question the physician’s insurance network coverage. However, if you have time, it’s a good thing to make sure your attending physician is part of your health network.

Tags: Revenue Cycle Management (RCM), Healthcare Revenue Billing, Insurance Billing Solutions, Medical Billing BPO, RCM Solutions, Revenue Cycle Solutions